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Transcription

1 Membe ership Guide Combined Evidence of Coverage and Disclosure Form Los Angeles County Effective July 1, 2012 Please read the following information so you will know from whom or what group of providers health care may be obtained. This combined evidence of coverage and disclosure form constitutes only a summary of thee health plan. The health plan contract must be consulted to determine the exact terms and conditions of coverage. Member Services: Tel (800) TTY 711 Monday through Friday, 8:00 a. m. to 8:00 p.m. PHC California P.O. Box Los Angeles, CA DHCS Form 1.0 Rev. 03/07/2016

2 This is information about your health care. It is important for you to understand this information. If you need help to translate this material or, to request this information in another language, large print, Braille or another format, please call (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. Este es información sobre su cuidado de la salud. Es importante que usted entienda esta información. Si usted necesita ayuda a traducir esta información o, solicitar esta información en otra lengua, letra grande, Braille u otro formato, por favor llame (800) , de lunes a viernes, a las 8h00 hasta las 20h00. Այս տեղեկությունը վերաբերվում է ձեր առողջությանը: Այս տեղեկությունը հասկանալը կարևոր է ձեզ համար: Եթե ձեզ օգնություն է հարկավոր այս նյութը թարգմանելու կամ այս տեղեկությունը ուրիշ լեզվով, մեծ տառերով, կույրերի Բրեյլ տառերով կամ տարբեր ֆորմատով ձեռք բերելու համար, խնդրում ենք զանգահարել (800) համարով, երկուշաբթիից ուրբաթ, առավոտյան 8:00-ից երեկոյան 8:00-ը: Эта информация касается Вашего медицинского обслуживания. Очень важно, чтобы Вы поняли данную информацию. Если Вам требуется помощь в переводе этого материала, или если Вы желаете получить эту информацию на другом языке или в другом формате, включая форматы крупного шрифта или шрифта Брайля, пожалуйста, позвоните по номеру (800) с понедельника по пятницу, с 8:00 до 20:00. این اطلاعات در مورد بیمە درمانی شما میباشد. برای شما مھم است که این مطالب را به خوبی درک کنید. چنانچه برای ترجمه این مطالب به کمک نیاز دارید یا خواھان دست یابی به این اطلاعات به زبانی دیگر حروف بزرگتر بریل (Braille) یا فرمت دیگری ھستید لطفا در روزھای دوشنبه تا جمعه بین 8:00 صبح تا 8:00 بعدازظھر با شمارۀ تلفن (800) تماس بگیرید. Ang impormasyong ito ay tungkol sa iyong pagkalinga sa kalusugan. Napakahalagang maintindihan mo ang impormasyong ito. Kung kailangan mo ng pagsasalin sa materyales na ito o, hilingin sa ibang wika ang ipormasyong ito, malaking letra, Braille o ibang format, maaaring tawagan (800) , Lunes hanggang Biyernes, 8:00 ng umaga hanggang 8:00 ng gabi. 本信息与您的健康护理有关 了解本信息对您是重要的 如果您需要他人帮忙翻译本材料 想索取本材料其它语言的翻译本 大字体 盲文或另一个格式的版本, 请在周一至周五上午 8:00 至下午 8:00 致电 (800) 本資訊與您的健康護理有關 瞭解本資訊對您是重要的 如果您需要他人幫忙翻譯本材料 想索取本材料其它語言的翻譯本 大字體 盲文或另一個格式的版本, 請在周一至周五上午 8:00 至下午 8:00 致電 (800) 이정보는귀하의의료에관한것입니다. 이정보를반드시이해하도록하십시오. 번역에도움이필요하시거나, 이정보를다른언어, 대형활자, 점자또는다른형식으로요청하시려면, 월요일에서금요일, 오전 8 시 00 분부터오후 8 시 00 분사이에 (800) 로전화해주십시오. BtámanenHKWs IGMBIkarEfTaMsuxPaBrbs'G~k. vakwcasar:smxan'smrab'g~k edimºiyl'dwgbtámanenh. ebisincag~k tuvkar CMnYy edimºibke bbtámanenh ÉebIcg'es~IsMuBtámanenHCaPasaep getot CaGk rbumõfm@ CaGk rsmrab'cnbikarep~k Ék*Ca TMrg'ep getot sumturs&bæetaelx (800) BI«f c&næ rhutdl'«f sü k BIemÔag 8:00 Bwk dl' 8:00 l ac. Thoâng tin naøy laø veà söùc khoûe cuûa quyù vò. Ñieàu quan troïng laø quyù vò hieåu roõ thoâng tin naøy. Neáu caàu ñöôïc giuùp ñôõ ñeå phieân dòch taøi lieäu naøy hoaëc, ñeå yeâu caàu thoâng tin baèng ngoân ngöõ khaùc, khoå in to, chöõ Braille hoaëc ôû daïng khaùc, xin goïi soá (800) , Thöù hai ñeán thöù Saùu, 8:00 saùng ñeán 8:00 chieàu.

3 Table of Contents Section 1: Introduction... 1 What to Do Next... 1 Who Can Enroll in PHC California?... 4 Member Rights and Responsibilities... 5 Identification (ID) Card... 5 If You Lose Your ID Card... 6 Changing Your Primary Care Provider... 6 Prepayment Fees (Premiums), Deductibles and Cost-Sharing... 6 If You Get a Bill from a PHC California Provider... 6 Specific Health Benefits... 7 Section 2: Getting Medical Services... 8 Choice of Physicians and Providers... 8 Facilities... 9 Liability of Enrollee for Payment... 9 Primary Care Provider Referral and Prior Authorization Services that Do Not Require Referral Standing Referral and Authorization Routine and Preventive Care for Women Certified Nurse Practitioners Access to a Health Care Provider 24 Hours a Day After-Hours Nurse Advice Line Urgently Needed Care Services Emergency Care Out-of-Area Emergency Care Post-Stabilization Care Continuity of Care Care for High-Risk Pregnancies Emergency Transportation Hospital Care Outpatient Services Asking the Plan to Reimburse You for Covered Services You Paid Out-of-Pocket Second Medical Opinion Transportation Services Certified Nurse Midwives Services for Veterans of the US Military Section 3: Covered Services Covered Services... 21

4 Inpatient Hospital Services Preventive Care Family Planning Services Maternity Care Laboratory, X-Ray and Imaging Services Home Health Care Services Hospice Sexually Transmitted Disease Testing, Counseling and Treatment Transportation Services Investigational Services Long-Term Care Health and Wellness Benefit Coverage Limitations Section 4: Services Available Outside of the Plan Alcohol and Substance Abuse Treatment Mental Health/Behavioral Health Services Transplant Services Section 5: Excluded Services Services Excluded from PHC California Services Excluded from Medi-Cal and PHC California Section 6: Prescription Drug Benefit Prescription Drugs Formulary Changes to the Formulary Prescription Drug Prior Authorization Asking for an Exception Using Network Pharmacies Out-of-Network Pharmacies Asking the Plan to Reimburse You for Prescription Drugs You Paid Out-of- Pocket Section 7: Disease Management What Is Disease Management? Your Registered Nurse Case Manager Initial Health Assessment Periodic Health Assessments Working with Your Primary Care Provider Medication Adherence Taking Care of Yourself Member Education Section 8: Other Programs Education and Other Wellness Information ii -

5 Women, Infants and Children Program Organ Donation Section 9: Access to Services Access Standards Language Assistance Hearing Assistance Federally Qualified Health Centers Indian Health Clinics Informed Consent Confidentiality Medi-Cal Covered Health Services Cultural Competency Americans with Disabilities Act Provider Moral Objection to Certain Services Section 10: Enrollment, Disenrollment and Eligibility Voluntary Enrollment Enrollment Application Process Three-Day Rescission Period Enrollment Confirmation Moving Out of the Service Area Voluntary Disenrollment Involuntary Disenrollment and Termination of Benefits Loss of Medi-Cal Benefits Transitional Medi-Cal Section 11: Advance Directive Making Your Medical Decisions Known Five Wishes Advance Directive Section 12: Complaints and Grievances Filing a Complaint or Grievance Filing an Grievance about an Action (an Appeal ) Your Right to Request an Independent Medical Review Continuation of Benefits Expedited Grievance Process Medi-Cal Fair Hearing Process Exhaustion of the Complaint and Grievance Process Section 13: Member Rights and Responsibilities Section 14: Information about PHC California Quality and Member Satisfaction Information Participating in PHC California s Public Policy Health Plan Contract with the State iii -

6 Section 15: Fraud and Abuse Section 16: Notice of Privacy Practices Who Will Follow this Notice Our Pledge and Responsibilities Regarding Your Medical Information How We May Use and Disclose Medical Information about You Special Situations Your Rights Regarding Medical Information about You Changes to This Notice Concerns about Our Use of Your Medical Information Other Uses of Medical Information Section 17: Glossary of Terms iv -

7 Section 1: Introduction This Membership Guide is for all PHC California members. This publication is also called the Evidence of Coverage and Disclosure Form. Please read it carefully. It will tell you how the health plan works, how to get the benefits that the plan offers, and you what you need to know about your health care plan. It also explains what PHC California covers and does not cover. Keep this handbook in a safe place so you can refer to it in the future. PHC California is a specialty care health maintenance organization (HMO) and health plan. It is designed to provide medical care for members who have a prior AIDS diagnosis. PHC California aims to improve the lives of its members. We help you and your providers manage your disease. This helps to avoid medical crises. PHC California stresses prevention through education. We promote lifestyle changes and improve medical self-management. Our goal is increasing member and family satisfaction. This combined evidence of coverage and disclosure form constitutes only a summary of the health plan. The health plan contract must be consulted to determine the exact terms and conditions of coverage. If you have any questions about the information in this handbook, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. The plan can provide language translation services if needed. There is no charge for these services. Throughout this publication, we will refer to PHC California as either the health plan, the plan, we, and our. What to Do Next There are a few steps you should take to start using PHC California: 1. Check your member identification (ID) card You should get your PHC California ID card either with this Membership Guide or by itself. If you have not gotten your ID card, please call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call

8 Whenever you need health care, give your ID card to your health care provider. Your card contains information about your health care coverage. Be sure to keep this card and your Medi-Cal card with you at all times and in a safe place. Please look at the information on your ID card. Check the name of the primary care provider (PCP) on the card to be sure it is doctor you chose. If you did not choose a PCP, we chose one for you who is closest to your residence. You cannot choose more than one PCP. The PCP you pick is important. You must see the PCP to whom you are assigned. If you want to change your PCP for any reason, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. The date your health plan coverage starts is shown on your ID card. 2. Complete and return the forms in your new member welcome packet The letter in your new member welcome packet tells you which forms you need to complete, sign and return to PHC California. These are forms like the Authorization for Use or Disclosure of Health Information, and Primary Care Provider (PCP) Selection/Change Form. See the letter in your new member welcome packet for more information. If you have any questions about these forms, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call Transfer your medical records to your PHC California PCP Please ask your current PCP to send your medical records to your new PHC California PCP. You can also ask your new PCP to ask your old PCP for your medical records. If your PCP is already in the PHC California network, this does not apply. If you need any help with this, you can call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call Learn about PHC California s disease management program PHC California uses a systematic approach called disease management to help you manage your illness. The program focuses on helping you follow your treatment plan. A part of the program is having a nurse work with you. The nurse will help you coordinate your health care needs

9 PHC California provides you with a Registered Nurse Case Manager (RNCM) within 30 days from the date you first join the health plan. You should expect a meeting with your RNCM for a health assessment within 90 days from the day you become a member. Your RNCM will contact you to set up the meeting. Your RNCM will be an important source of help for you. Your RNCM will call you every once in a while to see how you are doing. Your medical and behavioral health needs will help him or her decide how often they will call you. To contact your RNCM or if you have any questions about the program, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. To learn more about the disease management program, see Section 7: Disease Management. 5. Visit your primary care provider (PCP) Your PHC California primary care provider (PCP) is the doctor who will take care of all your routine medical care. Your PCP will arrange for any specialists or hospital care you need. Call your PCP at the number on your ID card for non-emergency health needs. PHC California doctors are fully credentialed. They are ready to see you. We check their education and training. We look at their experience. See your PCP within 90 days of you becoming a PHC California member. Even if you have seen a PCP recently, you should still see your new PCP. If you are pregnant, see your doctor within 30 days from the date of your joining the plan. Your start date with PHC California is printed on your ID card. It is important that you get to know your PCP. Also, your PCP needs to get to know you. Call your doctor s office to make an appointment for a checkup. 6. Know what to do in a medical emergency For a medical emergency, call 911 or go to the nearest emergency room. This Membership Guide explains more about your health plan and how to get health care. Please read it carefully. Pay special attention to the Emergency Care section. There is a list of examples of what is a medical emergency

10 7. Know where to go if you need help or have questions about the plan Call us with questions about the health plan and your benefits. We are here to help you. Interpretation services and other communication options are available, free of charge, for all foreign languages. Member Services representatives are available to help you Monday through Friday, 8:00 a.m. to 8:00 p.m. Call (800) , TTY 711. Important Telephone Numbers Your Primary Care Provider (PCP) On the front of your ID card PHC California Member Services (800) Monday through Friday, 8:00 a.m. to 8:00 p.m Pharmacy (Prescription Drug) Benefit Line (888) After Hours Nurse Advice Line (800) Case Management (800) Transportation (Call Member Services) (800) Medi-Cal Information Hotline (Los Angeles (877) County) Fraud and Abuse Hotline (800) Medi-Cal Fraud Hotline (800) California Department of Social Services State (800) Hearings Division (State Fair Hearing) TTY (800) California Department of Health Care Services (888) Office of the Ombudsman, Medi-Cal Managed Care Division California Department of Managed Health Care (888) HMO-2219 Help Center TTY (877) TTY users should call 711 for the above phone numbers unless otherwise noted. Who Can Enroll in PHC California? PHC California is a specialty care health maintenance organization (HMO) that serves Medi-Cal-eligible adults (21 years and older) who live in Los Angeles County and have a prior AIDS diagnosis

11 Medi-Cal is the state and federal partnership that provides health coverage for selected groups of children and adults with low incomes. Three basic groups may receive Medi- Cal: People in Supplemental Security Income (SSI) program Children and families in the Temporary Assistance for Needy Families (TANF) program Aged, blind, and disabled people, including people needing institutional care (also known as SSI-related Medi-Cal) A person must qualify in order to receive Medi-Cal. The Social Security Administration sets the rules to receive the SSI program. The California Department of Health Care Services (DHCS) qualifies all other Medi-Cal requirements, including programs for children and families; aged; blind and disabled; and institutional care. After you are approved for Medi-Cal, you will be sent information on managed care providers in your area, like PHC California. You may choose a plan or select Regular Medi-Cal (fee-for-service). Joining the plan is voluntary. If you wish to leave PHC California, you may do so at anytime. Effective date of disenrollment is usually the first day of the following month. To disenroll, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Member Rights and Responsibilities California regulations require that your health plan and health care providers recognize your rights. You must respect the rights of your providers too. Please read an outline of your rights and responsibilities included in this Membership Guide. Identification (ID) Card Every member of PHC California will get an ID card. Show this ID card and your Medi- Cal beneficiary identification card (BIC) to doctors when you get health care. Show it to hospitals and pharmacies too. This card shows you are a member of PHC California. Keep it with you at all times. Do not let anyone else use your card. If you do, you could lose your benefits

12 Your PHC Californiaa member identificatio on/pharmacy card looks like this: Front Back If You Lose Your ID Card If you lose your PHC Californiaa ID card, call Memberr Services at (800) , Monday through Friday, 8:00 a.m. to 8: 00 p.m. TTY users call 711. Confirm your mailing address and we will send you a new card. If you lose your Medi-Cal card, also known as your beneficiary identification card (BIC), call the Los Angeles County Department of Public Social Services at (877) Changing Your Primary Care Provider You can change your primary care provider (PCP) att any time. If you want to change your PCP, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Prepayment Fees (Premiums), Deductibles and Cost-Sharing There are no premiums to be member of PHC California. There are no deductibles or co-payments for covered services when you get them from providers who are part of the PHC California network and you follow the ruless for gettingg medical services. See Section 2: Getting Medical Services and Section 3: Covered Services. If You Get a Billl from a PHC California Provider If you get a bill from a doctor or a billing company for a servicee while you are a PHC California member and you do not think that you owe any money, pleasee call Member Services at (800) , Monday through Friday,, 8:00 a.m. to 8:00 p.m. TTY userss call 711. PHC Californiaa members are not responsible for any amounts owed to providers that the health plan should pay

13 Specific Health Benefits For information on these benefits, please see Section 3: Covered Services

14 Section 2: Getting Medical Services Choice of Physicians and Providers PHC California contracts with primary care providers (PCPs), specialists, hospitals, skilled nursing facilities and other providers to provide care to our members. These doctors, hospitals and other providers make up PHC California s provider network and are called network providers. We pay our network providers a set negotiated rate for the health care services they provide to our members. We do not pay our network providers bonuses or incentives to care for PHC California members. You may go to any network provider for your health care; however, most services except those described later in this section require a referral from your primary care provider (PCP) and authorization from the plan. This is explained later in this section. You can see a list of network providers in PHC California s Provider and Pharmacy Directory. If would like information about network providers in your general geographic area, please call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Some providers in PHC California s provider network may contract with licensed nonphysician providers to provide health care services to members. If a provider you see has such an arrangement, please ask your provider for a list of non-physician providers with which it has contracted. Some doctors may not perform certain services based on religious or moral beliefs. Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call the health plan at (800) (TTY 711), Monday through Friday, 8:00 a.m. to 8:00 p.m., to ensure that you can obtain the health care services that you need. If you have questions about the plan s provider network or how we pay our providers for the services they give to members, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call

15 Facilities The PHC California Provider and Pharmacy Directory lists primary care providers (PCPs), specialists, hospitals, skilled nursing facilities (SNFs), and ancillary service providers that are contracted with the plan to provide services to members. The directory lists network provider and facility locations, provider office hours and phone numbers. Hospitals listed in the Provider and Pharmacy Directory are available 24 hours a day, seven days a week for emergency services. If you think, you have an emergency medical condition, call 911 or go to your nearest hospital emergency room. You can go to a hospital out of network for emergencies. See Emergency Care in this Section for more information. You should receive a Provider and Pharmacy Directory along with this Membership Guide when you join PHC California. If you don t have a copy of the Provider and Pharmacy Directory, please call Member Services to request a copy or if you need help finding a provider or facility. Call (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. You can also see the most up-to-date Provider and Pharmacy Directory on the plan s website. Go to Liability of Enrollee for Payment You must get your health care from network providers except in very limited circumstances, such as if you need emergency care or urgently needed care. This is explained later in this section. If you go to providers who are not part of PHC California s provider network (these are called out-of-network providers) without advance approval (authorization) from us, you will have to pay for any services you get on your own. The exception is if you need emergency care, urgently needed care, or you need health care services that are not available in-network. If you go to a network provider for services without getting a referral and authorization from the plan, you may have to pay for these services yourself. The exception is if you need emergency care or urgently needed care. For non-urgent or non-emergent services, if you are unsure if you need a referral and authorization, call Member Services or your primary care provider (PCP) before you get - 9 -

16 health care services. Member Services is available Monday through Friday, 8:00 a.m. to 8:00 p.m. at (800) TTY users call 711. Primary Care Provider When you enroll, you choose a primary care provider (PCP) from the plan s list of network PCPs. If you do not choose a PCP, we will choose one for you who is closest to your home address. Your PCP will provide you with your routine and urgent health care needs. Your PCP will arrange for any specialist or hospital care, if you needed it. You must see the PCP to whom you are assigned. Each PCP in PHC California s provider network is an HIV/AIDS specialist. Your PCP will provide you with routine primary care as well as HIV specialty care. Because each PCP is an HIV/AIDS specialist you will not need a standing referral to an HIV/AIDS specialist. Female members may choose an OB/GYN provider as a PCP provided that the provider meets the plan s PCP eligibility requirements. For non-emergency health needs, call your PCP at the number on your ID card. Let your PCP know that you are a PHC California member. Give your PCP your most recent contact information. Your PCP should be able to contact you at all times. Have your medical records sent to your new doctor if he or she does not have them already. Visit your PCP within three (3) months. Your PCP will: Provide well care Help you when you are sick Refer you for specialty care Give vaccine shots Order lab test and x-rays when needed Coordinate hospital care Assist you in getting emergency care You can change PCPs whenever you want and as often as you want. You cannot choose more than one PCP. If you would like to change your PCP, please call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Referral and Prior Authorization Your primary care provider (PCP) may not be able to provide all services. He or she may refer you to another provider for health care services. He or she may refer you to a hospital or specialist. Your doctor may not do lab work or x-rays. He or she may refer you to another place or someone else to get the tests done. Ask your PCP when a

17 referral is needed. If you are still unsure, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Your PCP will arrange for you to see other providers as necessary. You will need a referral from your PCP for all non-emergency care. For many services, your PCP will need to get an approval from PHC California before you can go to the specialist or provider to whom your PCP referred you. This approval is called a prior authorization. The services that require a prior authorization are described in Section 3 (Covered Services). PHC California processes routine referral and authorization requests within five (5) business days of receipt of the request from your PCP or other referring provider. Your PCP or other referring provider may make an urgent referral or authorization request because the normal authorization processing timeframe could cause you imminent and serious threat to your health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal timeframe for the decision making process would be detrimental to your life or health or could jeopardize your ability to regain maximum function. For these type of expedited referrals and authorization requests, the plan will process them in a timely fashion appropriate for the nature of your condition, not to exceed 72 hours or, if shorter, the period of time required under Section 2710 of the Federal Public Health Service Act and any subsequent rules or regulations issued there under, after the plan s receipt of information reasonably necessary and requested by the plan to make a determination. PHC California will notify your PCP or referring provider by telephone or fax within 24 hours from the time the plan has made a decision on an authorization request. If the plan denies, delays or modifies health care specified in the authorization request, PHC California will notify you and your provider in writing within two (2) business days from the time the plan made the decision. You will have the chance to appeal this decision (called a coverage determination ). See Section 12: Complaints, Grievances and Appeals. Services that Do Not Require Referral Family planning, sexually transmitted disease (STD) testing and counseling, and obstetrical and gynecological (OB/GYN) services do not require a referral from your PCP. You can go to any provider who accepts Medi-Cal for family planning and STD testing and counseling services

18 Standing Referral and Authorization Should your primary care provider (PCP) decide that you need continuing care from a specialist or coordination of care from a specialty center, your PCP will ask us to authorize a standing referral for a treatment specified by your PCP. A standing referral means a referral by a PCP to a specialist for more than one visit to the specialist, as indicated in the treatment plan, if any, without the PCP having to provide a specific referral for each visit. PHC California will make a decision on the authorization request for a standing referral within three (3) business days from receipt of the authorization request and all appropriate medical records and documentation needed to make such a decision (a coverage determination ). If we approve or authorize a standing referral, we and your PCP will give you the standing referral requested within four (4) business days of the date of the treatment plan. If you have any questions about a standing referral, ask your PCP or call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Routine and Preventive Care for Women Female members may go to any network specialist who provides women s routine and preventive health services, such as a gynecologist, without a referral from their primary care provider (PCP). To find women s health providers, look in the PHC California Provider and Pharmacy Directory. If you need help finding women s health providers, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Certified Nurse Practitioners Some PHC California primary care providers (PCPs) use Certified Nurse Practitioners to see their patients. Members may see a Certified Nurse Practitioner, however, they are assigned to a PCP, a physician, who oversees and has overall responsibility for member health care. To see a Certified Nurse Practitioner, or for more information, ask your PCP or call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Access to a Health Care Provider 24 Hours a Day PHC California members have access to a health care provider 24 hours a day, seven days a week. If you become sick and need care or have health or medication questions during business hours when your primary care provider's (PCP's) office is open, call your PCP. If you are sick and need care, your PCP will tell you what you should do. You PCP will also answer any questions you have about your health or care plan you are

19 following. Your PCP's phone number is on the front of your member ID card. If you call your PCP during business hours and he or she is not available, another doctor or health care provider will help you. You should not have to wait any longer than 30 minutes to talk to your PCP or another health care provider from your PCP's office when you call. If your PCP wants you to come to his or her office, you may get a same-day appointment. You PCP may tell you to go to an urgent care facility. It should take no more than 48 hours from the time you call your PCP to request an appointment to get urgently needed care services from your PCP. If you become sick or have health or medication questions when your PCP's office is closed, call the After-Hours Nurse Advice Line at (800) TTY users call 711. A nurse is available 5:30 p.m. to 8:30 a.m., Monday through Friday and 24 hours a day on weekends and holidays. See After-Hours Nurse Advice Line in this Section for more information. If you need urgently needed care when your PCP s office is closed or your PCP is not available and you are in the plan s service area, you may go to any urgent care facility in the plan s provider network. If you need urgently needed care and you are out of the plan s service area, you may go to any urgent care facility. PHC California will cover your urgently needed care. See Urgently Needed Care Services on page 14 in this section for more information. If you think you are having a medical emergency, call 911 or go to the nearest hospital emergency room. After-Hours Nurse Advice Line PHC California has an After-Hours Nurse Advice Line for non-emergency help. If you get sick and are not sure what kind of medical care you need or what to do, and you are not experiencing a medical emergency, call the After-Hours Nurse Advice Line. Call (800) ; TTY 711 During normal business hours, please contact your primary care provider (PCP). Your PCP s phone number is on the front of your member ID card. The After-Hours Nurse Advice Line is available 5:30 p.m. to 8:30 a.m., Monday through Friday and 24 hours a day on weekends and holidays. A nurse will answer your health care questions or concerns. This is a service that is no cost to you

20 When you call the After-Hours Nurse Advice Line, a nurse will ask about your condition. He or she will help you decide if you need to go to the hospital, go to an urgent care facility, see your doctor, or care for yourself at home. The nurse can help with illnesses such as: Feeling sick Fever or nausea Colds and flu Dizziness Cuts Back pain Coughing Burns Therapy (physical or occupational) Urgently Needed Care Services Urgently needed care is care needed right away, but is not an emergency. Urgently needed care prevents serious deterioration of the health of a member, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy. For pregnant members, urgently needed care includes maternity services necessary to prevent serious deterioration of the health of the member or the member's fetus, based on the member's reasonable belief that she has a pregnancy-related condition for which treatment cannot be delayed. Call your primary care provider (PCP) first if you need urgently needed care. Your PCP will give you choices for care. A choice may include going to an urgent care facility or a same-day appointment with your PCP.. It should take no more than 48 hours from the time you call your PCP to request an appointment to get urgent care services from your PCP. See the PHC California Provider and Pharmacy Directory for a list of network urgent care facilities. If you need urgently needed care, your PCP is not available and you are in the plan s service area, you may go to any urgent care facility in the plan s provider network. See the PHC California Provider and Pharmacy Directory for a list of network urgent care facilities. You can also call Member Services at (800) for help finding an urgent care facility. Member Services is available Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. If you need urgently needed care after-hours, weekends and holidays and need help finding an urgent care facility, please call the After Hours Nurse Advice Line at (800) TTY users call

21 If you need urgently needed care and you are out of the plan s service area, you may go to any urgent care facility. PHC California will cover your urgently needed care. Be sure to show your member ID card to the urgent facility staff. Emergency Care If you think, you have an emergency medical condition, call 911 or go to your nearest hospital emergency room. You can get emergency care 24 hours, seven days a week. You can go to a hospital out of network for emergencies. An emergency is a condition that you believe will cause any of the following, if you do not receive treatment at once: Serious harm to your health Serious injury to the body Serious damage of a body part Serious damage of an organ For pregnant women, harm to an unborn baby Some examples of emergencies may include: Heavy blood loss Heart attack Stoke Sudden blindness Severe allergic reaction Severe cuts requiring stitches Loss of consciousness Poisoning Severe chest pains Loss of breath Broken bones Behaviors (psychiatric conditions) that can cause danger or harm to yourself and others For pregnant women, these conditions and situations may be an emergency: Active labor Vaginal bleeding No movement from the baby If you think there is not enough time to go to your doctor s regular hospital If you think that going to another hospital may cause harm to you and your baby

22 Emergency psychiatric conditions are covered by the plan. If you experience an emergency psychiatric condition, call 911 or go to the nearest emergency room. Emergency psychiatric conditions mean a mental disorder severe enough to cause symptoms that it can cause an immediate danger to you or to others. These symptoms can also make you immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. You will need to show your PHC California ID card and Medi-Cal Benefits Identification card (BIC) at the emergency room. Ask the staff in the emergency room to call PHC California Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. Let your primary care provider (PCP) know as soon as you can when you are in the hospital. Let him or her know if you received care in an emergency room. The emergency room doctor will decide if your visit is an emergency. If it is not an emergency, you will be given the choice to stay or leave the hospital. If you choose to stay, you will have to pay for your care. Out-of-Area Emergency Care If you think, you have an emergency medical condition, call 911 or go to the nearest hospital emergency room. If you become ill while traveling and you do not think you are having a medical emergency, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. The staff can assist you with information about receiving care while away. You can also call the After-Hours Nurse Advice Line at (800) , TTY 711, for nonemergency help from 5:30 p.m. to 8:30 a.m., Monday through Friday and 24 hours a day on weekends and holidays. See After-Hours Nurse Advice Line on page 13 in this section. Post-Stabilization Care The treatment required following an emergency is called post-stabilization care. PHC California will cover follow-up care to emergency treatment that your doctor says is medically necessary. Prior approval is not required to receive this care. No authorization is required regardless of whether you receive this care within or outside of the PHC California network

23 Continuity of Care PHC California is committed to providing the medically necessary health care you need either through your primary care provider (PCP) or other providers as needed consistent with good professional practice. The plan is also committed to providing you any medically necessary care throughout the course of any treatment plans developed by your PCP or other provider. You have the right to completion of covered services. If you feel you are not receiving the care you need, please contact Member Services and file a grievance to document your concerns. You may also contact Member Services to request a copy of PHC California s continuity of care policy. Member Services is available Monday through Friday, 8:00 a.m. to 8:00 p.m. at (800) TTY users call 711. In the event you are receiving care for an acute condition, serious chronic condition, or terminal illness; or care of a newborn child between birth and 36 months from a provider who is leaving the plan s network before you finish your treatment from him or her, PHC California will attempt to work with that provider to make arrangements for you to complete your treatment with him or her. If you have surgery or other procedure that is authorized by us as part of a documented course of treatment and your provider has recommended and documented that the procedure occur within 180 days of the provider leaving the plan date, we will attempt to make arrangements with the provider to complete the procedure. If we cannot make such an arrangement, the plan will find a new network provider, or out-of-network provider if the provider you need is not in the network, to complete your treatment. For new enrollees into PHC California, the plan will make arrangements with providers you are currently seeing for the treatment of an acute condition, serious chronic condition, or terminal illness; or care of a newborn child between birth and 36 months. The plan will attempt to make arrangements with the provider from whom you are currently receiving treatment to complete that treatment. If we cannot make such an arrangement, the plan will find a new network provider, or out-of-network provider if the provider you need is not in the network, to complete your treatment. In the event your PCP leaves the plan, we will advise you 30 days before his or her departure from the plan and assign you a new PCP. You may keep the PCP we assign to you or change to another PCP. Remember, you may change PCPs whenever you d like. If you have any questions about PHC California s continuity of care policy or would like to change your PCP, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call

24 Care for High-Risk Pregnancies Pregnant members who are at risk for a complicated or poor pregnancy outcome will be referred by their primary care provider (PCP) or obstetrician to specialists who care for women with high-risk pregnancies, such as perinatologists and geneticists. If you are pregnant, please see an obstetrician as soon as possible to determine if you are at risk. Also let your PCP know that you are pregnant. If you need an obstetrician, look in the PHC California Provider and Pharmacy Directory. You can also call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Emergency Transportation Call 911 if you need emergency transportation to the hospital. Do not call 911 if you can get to the hospital on your own. Show your PHC California ID card for emergency transportation. Hospital Care Your doctor will help you choose a hospital. Talk to your doctor about your choices. You may have a hospital that you prefer. All non-emergency hospital care must be received from a network hospital except if you need hospital care that is not available from a network hospital. If you need care while away from Los Angeles County, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Outpatient Services Outpatient services are services provided to you at the hospital without a hospital stay. Your PCP can help you get these services. All non-emergency services require an approval. All services must be medically necessary to be covered by the plan. Outpatient services may include: X-rays Lab tests

25 Asking the Plan to Reimburse You for Covered Services You Paid Outof-Pocket If get out-of-network emergency care or urgently needed care when the provider network is not available and pay for this care yourself, you may ask us to reimburse you for the cost of this care. We will reimburse you for treatment you received at published Medi-Cal/Medicaid rates. To request reimbursement, please send us a copy of your itemized/detailed receipt for services with an explanation of the circumstances regarding the care you received to: Attn: Member Services PHC California P.O. Box Los Angeles, CA Second Medical Opinion You can call your primary care provider (PCP) and request a second opinion about your health care. If you are uncomfortable asking your PCP for a second opinion, you may call Member Services for help at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. You may choose a PHC California doctor listed in the Provider and Pharmacy Directory or a doctor who is in your service area but who is not a PHC California doctor. All tests that are ordered must be done by a PHC California in-network provider. There will not be a fee for obtaining a second medical opinion when seeing a PHC California doctor. If you choose a doctor who is not a PHC California doctor, you may have to pay a part of the bill for the second medical opinion. You may choose a second medical opinion if: You do not agree with the doctor s decision about whether you need a procedure or surgery You are suffering from a life-threatening injury or illness Your PCP will review the results of your second medical opinion. Your PCP will decide on a treatment plan that is best for you. If you disagree with this plan, you have the right to appeal this decision. The grievance process listed in this publication will tell you how. Treatment not authorized by PHC California will be at your expense. You or your doctor may ask PHC California for a faster, expedited, pre-service decision. If you think your life, health or daily function would be in danger if you have to wait for the approval, ask for an expedited pre-service decision. To request an expedited pre

26 service decision, call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. You can also fax your request to (888) Be sure to ask for an expedited review. Transportation Services PHC California covers non-emergency transportation to and from specialty providers greater than ten (10) miles away from your primary care provider s (PCP) office in medical transport vans, wheelchair vans, litter vans, and other vehicles. The plan will schedule the type of transportation you need based on your mobility. Call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. to schedule transportation. TTY users call 711. For emergency transportation, call 911 if you cannot get to a hospital yourself. Certified Nurse Midwives Certified Nurse Midwife services are available outside of PHC California s network. Members may see a Certified Nurse Midwife without primary care provider s (PCP s) approval. To find out more, ask your PCP or call Member Services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Services for Veterans of the US Military PHC California covers medically necessary care for veterans who have military serviceassociated disabilities for which care facilities are reasonably available. PHC California will provide such services and request reimbursement from the responsible entity after it provides them

27 Section 3: Covered Services This section tells you about the covered services and benefits you have while enrolled in PHC California. Call member services at (800) , Monday through Friday, 8:00 a.m. to 8:00 p.m., if you have questions about the services and benefits available to you. TTY users call 711. Covered Services A summary of the benefits and limits available through PHC California is below. THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Acupuncture Services Alcohol Abuse Treatment (See page 31 for more information about Alcohol and Substance Abuse Treatment.) Allergy Care Ambulance Services Ambulatory Surgery at an Ambulatory Surgery Center Case Management and Disease Management Services Certified Nurse Midwife Services Certified Nurse Practitioner/Physician Assistant Services Limitations Covered when medically necessary; no limits; no co-pay; requires prior authorization Available through the Los Angeles County Public Health Substance Abuse Prevention and Control Program. PHC California will refer you for such services if you need them. Covered when medically necessary; no limits; no co-pay; requires prior authorization For emergencies; covered when medically necessary; no limits; no co-pay Covered when medically necessary; no limits; no co-pay; requires prior authorization Covered; no limits; no co-pay Covered; no limits; no co-pay Covered when medically necessary; no limits; no co-pay; certain services require prior authorization

28 Services Chiropractic Services Clinical Services from Los Angeles County Health Services Clinics Clinical Services from Federally Qualified Health Centers (FQHCs) and Indian Health Clinics Clinical Services from Rural Health Clinics (RHCs) Dermatology Services Dialysis Services (hospital-based and free standing) Durable Medical Equipment and Medical Supplies Emergency Room Services Family Planning Services (See page 27 for more information about Family Planning Services.) Hearing Aids Home Health Care Services (See page 28 for more information about Home Health Care Services.) Limitations Covered when medically necessary; limited to two (2) services per month; limited to the treatment of the spine by means of manual manipulation; procedures require prior authorization Primary care and preventive physician services covered; limit of one (1) visit per day; no co-pay Primary care and preventive physician services covered; limit of one (1) visit per day; no co-pay Primary care, preventive physician and laboratory services covered; limit of one (1) visit per day; no co-pay; certain laboratory services require prior authorization Covered when medically necessary; no limits; no co-pay; certain services require prior authorization Covered when medically necessary; no limits; no co-pay; requires prior authorization Covered when medically necessary; no limits; no co-pay; certain services require prior authorization Covered when medically necessary; no limits; no co-pay Covered; no limits; no co-pay. Available through any participating Medi-Cal provider. Covered when medically necessary; no limits; no co-pay; certain services require prior authorization Covered when medically necessary; no limits; no co-pay; certain services require prior authorization